Report of the Gerontological Advisory Council

Executive Summary

Canada's surviving war veterans – the men and women who served in World War I, World War II and the Korean War – now range in age from 70 to 106. Like all older Canadians, they are coping with the effects of aging. Unlike other Canadians, they may also be coping with the long-term impact of military service on their health.

The Impact of Aging on Health

As people age, they become more vulnerable to the kind of life course events that can lead to frailty and a loss of health or independence -- such as a chronic illness, a serious fall, the illness or death of a spouse, the loss of income, the loss of a driver's license or social isolation. Their health and well-being can deteriorate over time; however, frailty is not inevitable.

When older people have access to integrated health and social services, including information and activities that help them enhance their health, they have more opportunity to age well. Integrated models of care lead to better health, quality of life and satisfaction for older adults, and reduce both the burden on family caregivers and health care costs.

The Collective Responsibility to Support Veterans' Health and Well-being

In recognition of their military service, Canada's war veterans have the right to programs and services to protect and enhance their health. In the Department of Veterans Affairs Act, the Government of Canada made a commitment to provide care and treatment for any person who served in the Canadian Forces. Given recent research findings that stressful deployments can have latent long-term effects on health, it is particularly important for Canada to keep its promise to provide care for veterans.

Existing Programs and Services for Aging Veterans

Provincial health systems are responsible for ensuring that older veterans – like other Canadians – have access to publicly funded health services. In addition, Veterans Affairs Canada (VAC) currently provides three health and social programs designed to help veterans with needs that may not be adequately met through their provincial health system or private health insurance.

Historically VAC has been a leader in services for seniors by, for example, covering the cost of services such as housekeeping and groundskeeping services that help veterans remain in their homes, and providing a falls prevention program. VAC has adapted its health and social programs to meet veterans' changing needs by, for example, paying for veterans to receive long-term care in their communities rather than requiring them to leave their communities to move to a priority access bed in a large centre. VAC has also extended some health and social benefits, such as groundskeeping, to veterans' spouses when the veterans die.

While VAC's services have a lot of strengths, there are also some weaknesses. Access to these services is based on complex eligibility criteria, which mean that many veterans either do not qualify or do not use the services. The services tend to be reactive: they are available only when veterans develop health problems rather than helping them maintain their health. They are also limited to certain types of benefits. For example, VAC will pay for a veteran's care in a long-term care home, but will not contribute to the cost of a retirement home or assisted living unit, which may be more appropriate settings for many veterans.

A Proposal for Veterans Integrated Services

When asked about their health needs, veterans said they wanted more emphasis on health promotion and disease prevention, more community-based care and more flexible services to meet their needs and help them delay or avoid the need for long-term care.

To help veterans and their families enhance their well-being and quality of life, age as well as possible, and receive care to support them as their lives end, the Gerontological Advisory Council recommends that Veterans Affairs Canada:

• combine its three existing health and social programs to create the Veterans Integrated Services (VIS)
• make VIS available to all veterans who served in the armed forces during World War I, World War II and the Korean War and their families, with the services they receive based on their health needs rather than their veteran status
• provide a single entry point for all VIS services
• provide assessment services and ongoing monitoring of veterans' and their families' health needs
• expand or adapt the current interdisciplinary teams to include:
  • early intervention specialists who will work with veterans and families to enhance their health and help them navigate the health and social service systems
  • care coordinators who will help veterans and families with more health needs arrange the services they need
  • high needs care managers who will be responsible for organizing the care of veterans or family members who are frail or disabled, and need more intensive care and support.
• expand the services available to aging veterans to include appropriate early intervention and health promotion services, more intensive home supports and a wider range of residential choices for veterans
• ensure that the care managers have the flexibility to move and allocate resources to meet veterans' health and social needs and are available consistently to assist veterans
• work with veterans' organizations to inform all war service veterans about VIS
• develop a comprehensive database that can be used to evaluate and improve VIS.

The Benefits of Veterans Integrated Services

The proposed Veterans Integrated Services will be more comprehensive, flexible and responsive than VAC's current health programs. It will also reach more veterans and families, help them enhance their health and well-being, and give them access to more appropriate health and social services when they need them.

By providing more integrated, coordinated services, VIS will ensure that veterans do not slip through the cracks in provincial health systems. The Gerontological Advisory Council believes that VIS will not only lead to better quality service for veterans, but it will prove to be cost effective.

VAC has an opportunity once again to reset the bar for health and social services in Canada. It is possible to establish an integrated system of health and social services for war veterans that can enhance well-being, help people age well, allow our aging veterans to spend their later years where they want to be – with family and friends, and avoid or delay the need for institutional care. The Gerontological Advisory Council believes VIS has the potential to be a model of care for all older adults, and to set the principles for future services for Canadian Forces Veterans as they age.

A Call to Action

Most of Canada's war veterans are in their 80s, and about 2,000 are dying each month. If we are to make a difference in the quality of their and their families' lives, we must act quickly, and we must act now. It is time to keep the promise.

Members of the Gerontological Advisory Council

The Gerontological Advisory Council draws its membership from some of Canada's most distinguished experts on aging, seniors' and Veterans' issues. Council membership and representation include scholars and researchers, practitioners and health service providers, veterans and veterans' organizations. Council members are:

• Victor Marshall, PhD (Chair)*
  University of North Carolina
• Dorothy Pringle, RN, PhD*
  University of Toronto
• Norah Keating, PhD*
  University of Alberta
• François Béland, PhD*
  Université de Montréal
• Evelyn Shapiro, MA LLD
  University of Manitoba
• Christopher MacKnight, MD, FRCPC
  Dalhousie University
• Bernard Groulx, MD, FRCPC
  Ste. Anne's Hospital
• Robin Poole, PhD
  McGill University
• Howard Zacharias, MD
  Southeast Regional Health Authority, MB
• Douglas H. Rapelje (Retired)
• Colonel Donald M. Thompson, CD (Retired)
• Senator Orville H. Phillips (Retired)
• Pierre Allard
  Royal Canadian Legion
• Jean McMillan
  War Amputations of Canada
• Kenneth W. Henderson
  Army, Navy & Air Force Veterans in Canada

*Members of the Futures Committee of Council

The Chair of the Gerontological Advisory Council wishes to express his deep appreciation to Dr. Dorothy Pringle for her leadership of the Futures Committee of Council, and to the Futures Committee members, Dr. François Béland and Dr. Norah Keating, as well as to all Council Members for their thoughtful and constructive contribution to the report.

The Futures Committee also wishes to acknowledge the significant contributions of Sean Farrelly, Dr. David Pedlar, Louise Wallis and other Veterans Affairs Canada personnel in the development of this Paper. As well, the Committee wishes to recognize the superb writing skills of Jean Bacon.

For further information about this paper and the work of the Gerontological Advisory Council, please visit the VAC website at www.veterans.gc.ca.

Preface

Canadians owe a debt of gratitude to men and women in uniform who put themselves at risk on our behalf. Veterans Affairs Canada (VAC) exists to repay the nation's debt to the members of our armed forces. Its mission is:

• To provide exemplary, client-centred services and benefits that
• respond to the needs of veterans, our other clients and their families,
• in recognition of their services to Canada
• and to keep the memory of their achievements and sacrifices
• alive for all Canadians.

Throughout its history, VAC has worked closely with veterans' groups to understand veterans' changing needs and to adapt its programs to meet those needs. In fact, VAC has been a leader in developing models of care and support for veterans: many of its innovations have shaped services for the broader Canadian population.

In 2005, the Year of the Veteran, Canada introduced the New Veterans Charter, legislation designed to modernize VAC's services and programs. The changes are designed to help the department meet the unique needs of younger modern-day Canadian Forces veterans who are usually in their mid-thirties when they leave the armed forces and who, along with their families, may need assistance making the transition to civilian life.

Because of its ongoing commitment to war veterans, in 2005 VAC also asked the Gerontological Advisory Council for advice on the best way to support the health, wellness and quality of life of the veterans of World War I, World War II and the Korean War, who now range in age from 70 to 106.

In this report, the Gerontological Advisory Committee recommends that VAC amalgamate and enhance its current health programs and services for war veterans to create Veterans Integrated Services (VIS). The report:

• describes the impact of aging on health and provides a conceptual framework that can be used to promote healthy aging
• discusses the current health status of Canada's aging war veterans, taking into account recent research on the long-term effects of military deployment
• summarizes the strengths, gaps and opportunities in VAC's current health programs
• sets out the steps required to build on existing programs to create VIS and enhance health and well-being for Canada's war veterans.

Call to Action

The Gerontological Advisory Committee urges Veterans Affairs to move quickly. Like all older Canadians, our war veterans are coping with the effects of aging. Unlike other Canadians, they are also coping with the long-term effects of military service. There is a small window of opportunity to make a real difference in the quality of their lives. Between March 2005 and March 2006, an estimated 24,500 war service veterans died. For each month it has taken to prepare this report, about 2,000 war veterans have died. There is no time for extensive debate; there is only time to act. It is time to keep the promise.

I. Understanding Aging and Aging Well

There are many pathways in aging.

Some older adults stay well and active until they die. Some experience stresses, such as social isolation or low incomes that affect their well-being. Some develop chronic or disabling conditions but -- either on their own or with assistance from family or health and social services -- are able to cope and remain at home until they die. Some become quite frail and need extensive support and care in their later years. Many need intensive end-of-life care, either at home or in an institution.

The Determinants of Health

• income and social status
• social support networks
• education and literacy
• employment and working conditions
• social environments
• physical environments
• personal health practices and coping skills
• genetic endowment
• health services
• gender
• culture

Health Canada and the World Health Organization use a life course model to help understand the different pathways to aging. This model postulates that there are three major social determinants of well-being and vulnerability in later life: health, wealth (i.e., income security) and social integration.

Any negative life course event, such as a long history of smoking or alcohol use, the development of a chronic illness, a serious fall, the illness or death of a spouse, the loss of income, or the loss of a driver's license can affect an older person's ability to cope or to remain independent in daily activities. Any negative life course event can start a vulnerable person on a trajectory toward frailty. As people age, they become more vulnerable to the kind of life course events that can lead to frailty, and their health and well-being can deteriorate over time.

According to a recent study of older adults living in the community, 70 out of 1000 people between the ages of 65 and 74 were frail compared to 175 per 1000 people age 85 and older.^Footnote1 About 10 to 20%of older people are frail.^Footnote2 However, as the following schematic illustrates, frailty is not inevitable.

Figure 1

1. Some people remain well, active and socially integrated during their later years. They may need information and some support to stay well, but they use few health or social services. Their health remains good until they experience an incident like a heart attack or stroke leading to immediate death.
2. Some people develop a chronic health condition or experience a devastating loss that will threaten their health and well-being, and start them on the route to frailty; however, with the right mix of health and social services and supports, they will be able to regain some health and independence.
3. Some people suffer some health or social loss – such as losing some mobility or function because of a chronic illness or losing a spouse – but they have access to community supports that mitigate the effects of the losses, do not become socially isolated, and are able to maintain some independence through the later years until death from a sudden illness or from a chronic disease.
4. Some people – about 10 to 20% of older people – will experience a level of disability or frailty that will require institutional long-term care. Many in this group will have dementia and require specialized care from trained providers over a considerable period of time until their death.

Many health risks increase with age.

Table 1: Prevalence of chronic conditions by age group, household population aged 30 or older, Canada, 2003

	65+ %	30-64 %
Arthritis/Rheumatism	47.3*	16.6
Cataracts/Glaucoma	24.7*	2.4
Back problems	24.1*	22.7
Heart disease	19.8*	3.5
Diabetes	13.5*	4.4
Thyroid condition	12.9*	5.9
Urinary incontinence	10.7*	2.3
Asthma	7.6	7.3
Bronchitis/Emphysema/ Chronic obstructive pulmonary disease	7.4*	3.1
Mental illness	6.1	8.8*
Cancer	5.5*	1.4
Migraine	5.4	11.9*
Effects of stroke	4.5*	0.6
Stomach/Intestinal ulcers	4.4*	3.2
Bowel disorder/Chron's disease/Colitis	3.9*	2.6
Chemical sensitivities	2.9	2.9
Alzheimer's disease/Other dementia	2.0*	0.1E
Fibromyalgia	1.9	1.9
Chronic fatigue syndrome	1.9	1.6
Epilepsy	0.6	0.6

Data source: 2003 Canadian Community Health Survey
Note: Based on self-reports from a checklist of diagnosed conditions.
* Significantly higher than estimate for other age group (p < 0.5)
E Coefficient of variation 16.6% to 33.3% (Interpret with caution)
F Coefficient of variation greater than 33.3% (suppressed because of extreme sampling variability)
Source: Statistics Canada; Health at Older Ages. Supplement to Health Reports. Volume 16.

According to the 2003 Canadian Community Health Survey, certain chronic conditions are much more prevalent in seniors than younger adults (see Table 1). For example:

• more than 50%of people over age 65 have arthritis and back problems, and 70%of people 75 or older have disabling arthritis ^Footnote3
• the prevalence of hypertension and diseases associated with hypertension, such as heart disease, diabetes and stroke, increase with age ^Footnote4
• about one-third of people over age 85 will have dementia ^Footnote5.

The average number of chronic conditions a person will have increases at older ages, from 1.9 for people between the ages of 64 and 74 to 2.5 for those 85 or older. ^Footnote6 Many chronic conditions are associated with loss of independence: older people with some chronic illness may need help with instrumental activities of daily living (e.g., running errands, doing housework, caring for lawns and gardens) or with activities of daily living (e.g., bathing, dressing). The likelihood of people becoming more dependent increases with the number of chronic conditions.

In 2003, about 6%of senior men and 7%of senior women needed help with activities of daily living, and 15%of men and 29%of women needed help with instrumental activities of daily living. ^Footnote7

The proportion of Canadian seniors who report being in good functional health and being independent in activities of daily living declines sharply with age. Only 37%of people 85 and older reported no disabilities, compared to 80%of people between the ages of 65 and 70. It is interesting to note, however, that even though people may lose some function as they age or need some assistance with activities of daily living, many still perceive themselves as "healthy" – although the proportion that do drops with age (see Figure 2).

Figure 2 – Percentage of people in good health, by age group, household population, aged 65 or older, Canada 2003

Percentage of people in good health(Text Version)	65 – 74	75 – 84	85 +
Overall good health	65%	45%*	22%
Good functional health	80%	64%*	37%*
Independent in activities of daily living	88%	70%*	41%*
Good self-perceived mental health	95%	93%	95%
Good self-perceived general health	79%	68%*	63%

Data source: 2003 Canadian Community Health Survey
+ Problem-free for all four components
*Significantly lower than estimate for previous age group (p < 0.05)
Source: Statistics Canada: Health at Older Ages. Supplement to Health Reports. Volume 16.

Because of physical weakness or hazards in the physical environment, older people are also at high risk of injuries from falls. Among Canadian seniors age 65 and older, falls accounted for 57%of deaths due to injuries among females and 36%among males. Many seniors who survive falls never fully recover. They lose function, have to live with chronic pain and often have to make lifestyle changes that affect their quality of life. Forty per cent of all nursing home admissions are associated with a fall. Falls also represent a major health care cost: $2.8 billion in 1994^Footnote8.

Some social risks increase with age.

With age, some people may become more socially isolated or marginalized. They may lose a spouse or partner, or many of their friends. There is also a group of marginalized seniors who tend to live alone or as part of a tight-knit couple, and are often excluded because of their tenuous social, economic or health status. These marginalized older adults often have small social networks and little connection to people in the community other than family. ^Footnote9This kind of social isolation may not be as problematic when they are younger but, as they age, it can make them more vulnerable to frailty. Their living arrangements, stress levels and lack of connection to their communities can affect their well-being as well as their ability to cope with any health or social stresses and to remain as independent as possible. ^Footnote10

Family relationships and responsibilities can affect health and quality of life.

Individuals do not traverse their life course alone: they lead "linked lives".^Footnote11, ^Footnote12 Families and friends play a key role in helping older people cope with stresses and maintain their independence.^Footnote13 Although people age 75 and over rely on assistance from social and health care programs, their families and close friends provide much of the support and assistance they require. ^Footnote14

An older couple may be able to continue living independently while both are well, but if one or both develop health problems, they may no longer be able to manage instrumental tasks or daily living tasks on their own. Given that the average lifespan for most Canadians is now over 80 years for women and 75 for men, the responsibility for care giving is falling on older frailer spouses, partners, and siblings, and on older children, who may themselves have age-related health problems. ^Footnote15

Family caregivers often provide care at great personal cost to themselves. Providing care to a spouse can have a direct effect on an older person's health and well-being. According to research done in the United States, family caregivers who provide care 36 or more hours a week are more likely than non-caregivers to experience depression or anxiety: for partners, the rate is six times higher; for those caring for a parent, the rate is twice as high. ^Footnote16 Family caregivers may also pay a price in terms of their social lives and incomes. According to Statistics Canada, a significant proportion of caregivers providing personal care for someone over age 65 report a loss in social activities, a drop in income, and an increase in costs. ^Footnote17 Caregivers also face great stress caring for someone with dementia because they no longer have the person's companionship.^Footnote18,^Footnote19

Income affects health and vulnerability.

Income is a key determinant of health. Socio-economic status early in life and later in life is related to health and to life expectancy. At each rung up the income ladder, Canadians have less sickness, longer life expectancies and improved health. ^Footnote20 People who have had higher incomes through life are likely to enjoy better health; they are also better able to buy the services and supports they need to help them age well. Low-income Canadians are more likely to die earlier and to suffer more illnesses than Canadians with higher incomes, regardless of age, sex, race and place of residence. ^Footnote21

A person's lifetime experiences affect well-being in later life.

The likelihood that individuals will develop health problems or become socially isolated in the later years and their ability to cope with those challenges depends to a large extent on their lifetime experiences. For example:

• people's behaviours in youth and as they age, such as smoking, alcohol use, body mass and physical activity, have an impact on well-being ^Footnote22
• married people have fewer acute and chronic conditions, fewer activity limitations and are less likely to become disabled or institutionalized ^Footnote23
• injuries or traumatic events early in life can affect health in the later years.

Poor health in later life is not inevitable.

As the Statistics Canada report on aging notes, "poor health in the senior years is not always inevitable ...[M]odifying certain risk factors may not only prolong life, but may also allow seniors to live more years in good health." ^Footnote24

Older adults who are aging well are able to develop and maintain optimal physical, mental and social well-being and function.

The World Health Organization (WHO) defines health as "a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity." ^Footnote25 This definition is echoed in the Veterans Health Care Regulations, which define health as "a state of physical, mental and social well-being".

The WHO defines health promotion as "the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy life-styles to well-being." ^Footnote26

The WHO definition is consistent with the Gerontological Advisory Council's concept of aging well, which is captured in the definition of "healthy aging" developed by the Healthy Aging Network in the US:

"... the development and maintenance of optimal physical, mental and social well-being and function in older adults. It is most likely to be achieved by individuals who live in physical environments and communities which are safe and which support the adoption and maintenance of attitudes and behaviors known to promote health and well-being; and by the effective use of health services to prevent or minimize the impact of acute and chronic disease on function."

Many different factors, working together, can enhance older adults' ability to age well.

As the following social-ecological model for health promotion illustrates (Figure 3), many different factors – from individual actions, to community activities and public policies – can support older adults in their efforts to age well.

Figure 3: Social Ecological Model

Physical Environment

Modified/Sources: McLeroy et al., 1988,
Health Educ Q; Sallis et al., 1998, Am J Prev Med

Individual actions, such as adopting healthier behaviours, can reduce vulnerability and promote well-being. As the Statistics Canada report, Health at Older Ages, notes, ^Footnote27 seniors – even seniors with chronic health conditions or other stresses in their lives -- are more likely to be in good health when they:

• are physically active three or more times a week
• drink alcohol moderately (i.e., weekly or occasionally)
• are a healthy weight
• eat fruits and vegetables at least five times a day
• do not smoke
• have low levels of stress in their lives
• have a strong sense of community belonging.

 

Figure 4 – Percentage in good health, by number of positive behavioural and psychosocial factors, household population, aged 65 or older, Canada 2003 (Text Version)

Number of positive health behaviours and psychosocial factors
0 or 1	2	3	4	5	6	7
18% E	34%*	42%	56%*	67%*	73%*	81%*

 

Data source: 2003 Canadian Community Health Survey
*Significantly higher than estimate for previous group (p < 0.05)
E Coefficient of variation 16.6% to 33.3% (interpret with caution)
Source: Statistics Canada; health at Older Ages. Supplement to Health Reports, Volume 16.

Seniors who have more of these positive factors are healthier (see Figure 4).

Fitness is particularly important in delaying or reducing frailty and can predict survival. ^Footnote28

Interpersonal activities, such as participating with other seniors in a walking club, joining a seniors' club or participating in community activities, can reduce social isolation and help older adults feel more connected to their communities. People who have a strong social network usually enjoy better health and perceive themselves as being healthier. ^Footnote29

Community activities, such as providing more walking paths, lighting streets, clearing snow from sidewalks and providing mall walking programs for older adults, promote physical activity and independence.^Footnote30,^Footnote31,^Footnote32,^Footnote33

Supportive physical environments can help people age well. Programs that adapt physical environments and reduce the risk of falls enhance well-being and independence. Recreation programs for seniors provide safe, age-appropriate opportunities to exercise. Curb cuts, appropriate transit services, longer light signals, larger type signs and other changes to the physical environment in the community make it easier for older people to remain mobile and active in their communities. ^Footnote34

Institutional efforts, such as providing access to health and social services, can enhance well-being and reduce vulnerability. Older people who have chronic conditions enjoy greater well-being and quality of life when their conditions are managed, their pain controlled and when they have access to health and social services that can help them remain as independent as possible. ^Footnote35 For example:

• effective primary care can identify early signs of chronic conditions, and help individuals manage them and maintain their health
• effective management of chronic conditions such as hypertension, diabetes, heart disease and osteoporosis can help people age well and remain independent longer
• services that help people manage instrumental activities of daily living, such as housekeeping and groundskeeping services, will allow people to remain independent in their homes longer
• comprehensive end-of-life care can allow people to choose to die at home.

Public policies can help ensure older adults have access to integrated health and social services that meet their needs. For example, policies that focus on providing care as close to home as possible, and keeping people in their communities can enhance well-being.

Comprehensive, integrated health and social services can enhance well-being in later life.

Canadian researchers have demonstrated that, by integrating health and social services for older adults, it is possible to provide cost-effective services and reduce rates of institutionalization. ^Footnote36, ^Footnote37 Integrated services for older adults include the following features: a single entry point to the system; case management; geriatric assessment and a multidisciplinary team; a focus on providing the right services in the right setting to meet the person's and family's needs; the ability to move resources to meet needs; and a focus on helping people remain in their homes and communities, and avoid or delay the need for institutional care for as long as is appropriate. ^Footnote38

In integrated models of care, older people are assigned to a care coordinator or case manager who is responsible for helping them obtain the information, health services and social services they need to maintain their health. This approach leads to improved health, quality of life, and satisfaction for older adults. It also reduces both the burden on family caregivers and health care costs. ^Footnote39, ^Footnote40

II. Canada's War Veterans: Their Rights and Needs

Canada's war veterans have the right to services to help them age well.

In the Department of Veterans Affairs Act, the Government of Canada made a commitment to provide "care, treatment or re-establishment in civil life of any person who served in the Canadian Forces or merchant navy or in the naval, army or air forces or merchant navies of Her Majesty, of any person who has otherwise engaged in pursuits relating to war, and of any other person designated by the Governor in Council". In recognition of their military service, Canada's war veterans have the right to programs and services to protect and enhance their health.

Military service can affect long-term health and well-being.

Most frequent VAC pensioned conditions:

• hearing loss
• musculoskeletal problems
• disc disease and spinal conditions
• gunshot wounds
• digestive system problems
• trauma (accidental)
• circulatory system
• other general diseases
• bronchi and lung conditions
• nervous system disorders

Older veterans experience the same challenges related to aging and life events as other Canadians, but they also face the added health effects associated with military service. Deployment can lead to immediate and long-term physical injuries. Stressful deployments can also have latent long-term health effects even for those who return from war seemingly physically unscathed and reintegrate into society.

According to a health study commissioned by the Department of Veterans Affairs in Australia, five decades after the Korean War, Australians who were deployed have poorer psychological health, poorer quality of life and are less satisfied with their lives than those who did not serve in the military. Compared to those who were not deployed, the Korean War Veterans were one and a half to three times more likely to have chronic medical conditions, such as asthma, high blood pressure, stroke, heart attack or angina, rapid or irregular heart beat, liver disease, arthritis, kidney disease, diabetes, melanoma, other skin cancer, other cancer, stomach or duodenal ulcer, partial or completely blindness, and partial or complete deafness. ^Footnote41

The same trend was identified in the 2003 Canadian Community Health Survey: a higher proportion of war service veterans reported having been diagnosed with arthritis or rheumatism than the Canadian population (see Figure 5). ^Footnote42 Arthritis may be more common in older veterans than in the population at large because injuries to joints, particularly the knees, ankles, hips, shoulders, hands, spine and feet, usually cause the onset of osteoarthritis in later life. ^Footnote43 These types of injuries are common in military training and on the battlefield, but their consequences (i.e., osteoarthritis) may not occur until decades after the injury when the link between military experience and the arthritis is not easily recognized.

Figure 5 – Percentage of Male Population Reporting Diagnosis of Arthritis/Rheumatism(Text Version)

65 + years	War Service	41%
	Canadian Population	38%
45 – 64 years	Regular Forces	25%
	Primary Reserves	27%
	Canadian Population	19%

Source: Canadian Community Health Survey 2003

Other studies have shown that all wars since the Civil War have been associated with a syndrome characterized by unexplained medical symptoms (now known as operational stress injury or post traumatic stress) that are difficult to define, connect directly to service or categorize as an illness. ^Footnote44, ^Footnote45, ^Footnote46

Because of their military service, war veterans may need health support and services to help them age well. As the authors of the Australian study note, "While we cannot change the war-related experiences ... health interventions have been shown to be effective in alleviating significant ill health experienced by aging veterans." ^Footnote47

As veterans age, it becomes virtually impossible – and unnecessary -- to determine whether any functional decline or loss of independence is due to aging, military service or a combination of the two.

A robust cohort of war veterans is now reaching old age.

As of 2006, an estimated 234,000 of Canada's war service veterans (WSV) are still alive. Of that number, three served in World War I, around 220,000 in World War II and 14,000 in Korea. They range in age from 70 to 106, and the majority (91%) are male. The average age of Korean veterans is 72. The average age of WWII veterans is 82. Two of the surviving WWI vets are 105 years old; the third is 106.

Figure 6, prepared by Veteran Affairs Canada, shows the aging of war veterans over time.

Figure 6 – The Aging of Canada's War Service Veterans Over Time(Text Version)

Ages	Number of Veterans
	1995	2000	2005	2010	2015
59	2,000
60	3,096
61	4,174
62	5,135
63	5,507
64	5,477	1,878
65	5,724	2,887
66	7,024	3,863
67	13,101	4,714
68	26,381	5,011
69	37,125	4,937	735
70	39,994	5,107	1,067
71	40,445	6,197	1,887
72	40,835	11,417	2,631
73	40,180	22,683	2,545
74	37,908	31,449	2,555	625
75	35,279	33,332	2,571	893
76	29,332	33,109	3,618	1,553
77	25,046	32,772	10,364	2,124
78	21,163	31,543	20,483	2,011
79	18,024	29,037	27,372	1,964	482
80	15,401	26,294	30,643	1,921	671
81	12,145	21,210	24,930	2,643	1,132
82	9,030	17,518	22,588	7,475	1,498
83	6,868	14,269	20,081	13,791	1,368
84	5,127	11,673	20,043	17,857	1,278
85	3,986	9,544	16,220	19,240	1,193
86	3,112	7,173	13,064	15,024	1,582
87	2,374	5,063	9,385	12,585	4,383
88	1,774	3,639	8,134	10,919	7,255
89	1,335	2,556	4,563	10,243	8,957
90	995	1,860	4,365	7,556	9,111
91	808	1,353	2,415	5,534	6,692
92	596	956	2,452	3,749	4,987
93	501	658	1,147	2,915	4,177
94	464	449	895	1,515	3,552
95	462	301	639	1,261	2,267
96	415	218	282	621	1,422
97	360	143	339	546	877
98	293	106	201	241	567
99	195	86	118	159	269
100	110	74	67	97	181
101	28	42	21	35	55
102	8	16	7	8	12
103	4	7	5	4	6
104	2	5	6	3	4

Source: Veterans Affairs Canada

The surviving war veterans have already outlived many of their peers: a sign of their ability to age well. Most war veterans are still living at home or in their communities -- many with the support of family and community services. Even those who need institutional long-term care tend to reach that stage late in life: the average age of veterans entering a long-term care home is 85.

However, all war veterans are now at a stage of life where they are more vulnerable to the negative effects of aging, which may be complicated by their military service.

About 40% of war service veterans are receiving some VAC health benefits now.

While many of Canada's surviving veterans appear to have aged well, they are not without health problems or needs. Of the estimated 234,000 war veterans, about 92,000 (40%) are already receiving VAC health benefits. Figure 7 illustrates the number receiving benefits by program (i.e., treatment benefits, VIP, and residential services or long-term care). Many veterans are receiving services from more than one program.

Figure 7 – Number of War Service Veterans Using VAC Health and Social Programs(Text Version)

Programs	Number of Veterans
	2004	2005
LTC	9730	9887
VIP	63231	61806
Treatment Benefits	95905	93248

Source: Veterans Affairs Canada

There are a number of reasons why the remaining 60% are not using VAC services:

• They may not meet the criteria for services (i.e., VAC health programs and services are currently based on categories of service and on complex eligibility criteria that require veterans to demonstrate either low income or a direct link between their health need and their wartime service).
• They may not know about the services that are available.
• They may not ask for service. According to a review of veterans' care needs done in 1997 and cited in the June 2005 Health Care Program Review, many veterans are reluctant to ask for help or are afraid to be turned down.. These findings were confirmed by recent research on older adults in rural communities, which found that some veterans who are less socially connected and, therefore, more at risk tend to be stoic and do not ask for assistance or services. ^Footnote48
• They may not need VAC services (i.e., they enjoy good health, they have the resources to meet their own needs or access to other employment and retirement health benefits).
• They may no longer live in Canada.

Veterans differ considerably in their health, financial and social resources.

Even veterans who appear to be coping well with aging often face serious risks and have unmet needs. According to recent research done for Veterans Affairs Canada, ^Footnote49 older adults living in rural communities differ considerably in their health, financial and social resources. They tend to fall into one of four groups:

"In every community, there are those frail elderly that are cared for at home by their families; there are elderly people who are living in isolation that have no one; there are those seniors who choose to live at risk because that's the way they've always done it... ther are people who are being cared for at a long term care facility; there are people... that are being cared for at home by home care, and receive respite... There are those who are active, there are those who [aren't], and there are those that are cared for."

From: Eales, J., Keating, N., Rozanova, J., Bardick, A., Swindle, J., Bowles RT., Keefe, J., Dobbs, B. (2006) Caring Contexts of Rural Seniors: A case study of diversity among older adults in rural communities. Veterans Affairs Canada.

• Community active seniors have large social networks, are engaged in their communities and have resources of energy, time, and skill. They are able to gain access to most services they need.
• Stoic seniors are reserved, independent, and practical. They have limited community involvement and prefer solitary over social activities. They believe that family and friends are available to help but do not ask for support. They are unlikely to request services and may not acknowledge a lack of resources.
• Marginalized seniors have limited financial income, very small social networks, limited connection to people in the community other than family, and precarious health. They may be isolated and invisible in their communities until a crisis arises.
• Frail seniors have significant health concerns that affect their daily living and patterns of engagement. They require assistance with activities of daily living, ranging from mobility aids to personal assistance to financial assistance. They differ considerably in their economic and social resources and are best supported when they have active family and friend networks that broker services.

Among all these groups, the need for services will vary. Some veterans will not need VAC services, while others will require extensive support.

Because most of VAC's health benefits programs and services for war veterans are not income based, data on income are limited. According to information from the 2003 Canadian Community Health Survey (CCHS), about 40%of veterans have low incomes, which puts them at higher risk of health problems. According to VAC's own statistics, about 40%of veterans in its programs are single (i.e., never married, divorced, spouse has died), which puts them at greater risk of social isolation.

Among those who are married, both partners are likely experiencing the health effects of aging, and will need support and care to avoid or delay frailty. One partner may also be facing the stresses associated with providing care for the other.

Demand for VAC's health services is increasing.

According to a recent review of VAC health care program expenditures, spending on all programs has increased and there has been a marked increase in the demand for certain Programs of Choice (POCs) including: prescription drugs, hospital services, audio services, special equipment and related health services.

VIP expenditures have also increased significantly, mainly due to spending on housekeeping, nursing home care, personal care, groundskeeping and nutrition – despite the fact that the number of veterans using VIP has dropped. This may indicate that the veterans using VIP are becoming more vulnerable and need more assistance with instrumental tasks. This possibility is consistent with the advancing age of the remaining veterans.

The increasing demand for VIP services and long term care beds may reflect the effects of a combination of advanced age and long-term effects of deployment.

At the current time, 25,000 widows who were primary caregivers of veterans or Canadian Forces veterans who received VAC's VIP benefits and who have now died, continue to receive housekeeping and groundskeeping services. Given the earlier Statistics Canada finding that a higher proportion of older women (29%) then men (15%) need help with instrumental activities of daily living, surviving primary caregivers may need more support in the future to be able to age well and remain independent.

Not all older veterans will need VAC services, and it is difficult to predict how many will require services and what mix of services they will need. What is absolutely predictable is that – because of their age -- the number of war veterans who require help will drop significantly over the next 15 years.

The challenge for Veterans Affairs Canada is to ensure that, while they are still alive, our war veterans have access to integrated services that address their physical, mental and social needs, reduce their vulnerability, help them age well, and provide high quality end-of-life care when they need it.

III. VAC Health Care Programs Now: Strengths and Weaknesses

Veterans Affairs Canada currently provides a number of health and social programs and benefits for aging veterans "designed to enhance the quality of life of VAC clients, promote independence, and assist in keeping clients at home and in their own communities by providing a continuum of care". ^Footnote50 These programs include:

• a health benefits program that offers services through 14 Programs of Choice, including medical, surgical or dental examinations, surgical or prosthetic devices or aids and their maintenance, home adaptations, preventive health care, prescribed drugs, and supplementary benefits, such as travel and accommodation costs to attend treatment
• the Veterans Independence Program, a national home care program that helps clients remain healthy and independent in their own homes and communities by providing services, such as housekeeping, grounds maintenance (i.e., snow removal, lawn cutting), personal care, home adaptations, nutrition services and transportation to social activities
• the residential care programs (i.e., long-term care beds), which used to focus solely on providing priority access to long-term care beds in a small number of facilities across the country, but now will also find and subsidize the cost of long-term care closer to home.

VAC is a "gap insurer", rather than the "first payer" for veterans' health services.

Under the Canada Health Act, provincial health systems are responsible for making sure that older veterans – like other Canadians – have access to publicly funded health services, such as primary care, specialist care, hospital services and other services, available in their province or territory. Some veterans may also have private insurance plans that cover some services not funded by their public system. VAC's health programs exist to fill any gaps and help veterans with health and social needs that may not be adequately met through their provincial health system or other health benefits.

The Gerontological Advisory Council is aware that two provinces have recently decided to exclude veterans from provincial subsidies for the cost of long-term care beds because Veterans Affairs Canada will pay for long-term care for veterans. The Gerontological Advisory Council would like to express its strong concern about this trend and reinforce that veterans should be entitled to all health services provided by their province and territory AND to VAC programs required to fill any gaps in their care.

Strengths

Existing VAC services have some significant strengths that should be used to form the basis for more integrated services for war veterans.

VAC's health programs have been far-sighted in their efforts to help older veterans maintain their independence.

The decision – as early as the 1980s – to establish the Veterans Independence program (VIP) and cover the cost of services such as housekeeping and grounds maintenance shows that VAC understands the complex factors that affect well-being and make people vulnerable as they age, as well as the type of services that can enhance independence. ^Footnote51 The decision to extend certain VIP benefits to surviving spouses at first for a year (1990) and then for their lifetime (2003) indicates that VAC understands the concept of linked lives and the important role the primary caregiver plays in providing care for the veteran.

In 2000, VAC worked jointly with Health Canada to establish the Falls Prevention Initiative, a community-based health promotion initiative to help identify effective falls prevention strategies for veterans and seniors. VAC funded 40 falls prevention initiatives and, as a result of this investment, was able to reach veterans living in the community, reduce their risk of fall, and enhance their well-being and independence. The best practices and program models identified by VAC are now being used widely to prevent falls.

VAC has adapted its programs to meet veterans' changing needs and preferences.

The shift away from providing long-term care beds in a few dedicated veterans' facilities to paying for or subsidizing long-term care closer to home indicates that VAC understands the importance of social integration, community and aging-in-place, and is willing to adapt its programs to meet veterans' needs.

Over the past few years, VAC has also started to shift to a more client-centred, case management model to support war veterans. VAC has established area counsellors who are quasi case managers responsible for determining a veteran's eligibility for services, linking the veteran to provincially funded services in their communities (e.g., home care, long-term care), and providing VAC services that can help fill any gaps between provincial services and the veterans' needs (e.g., VIP services). VAC has also developed multidisciplinary teams with expertise to assess veterans and make recommendations about appropriate services.

Veterans like the personal relationship they have with their VAC area counsellors.

Veterans report that they like having one person to contact at VAC for their services. They have built a trusting relationship with that person, and they know who to call when they need help. It's important to them to preserve that personal relationship.

Weaknesses

VAC's existing health programs also have some weaknesses that should be addressed to provide integrated services for older veterans.

Access to VAC's health programs is based on complex eligibility criteria.

Access to VAC's health programs involves complex eligibility rules. One of the key gaps is that Treatment Benefits and VIP are available to only a small proportion of veterans who either qualify by virtue of: receiving a disability pension, meeting a low-income test, being assessed as disabled, meeting criteria for exceptional health needs, or being on a waiting list for a priority access bed. As of March 2006, there were about 70,000 veterans who either do not qualify for or are not receiving VIP or Treatment Benefits services. VAC has made several attempts to address the anomalies in the legislation and successfully operated pilots in order to ensure that veterans have their health care needs met. Notwithstanding these efforts, certain veterans currently are not eligible and may be missed.

VAC's health and social programs are reactive rather than proactive.

While many of VAC's health and social services are designed to help older veterans remain independent, they are not available until veterans have already suffered some loss in functional ability. Reactive rather than proactive, VAC's programs are not designed to identify potential vulnerabilities early and take steps to enhance health and well-being. They do not begin early enough to help veterans avoid or delay health losses.

VAC's services do not give veterans a range of housing choices to meet their needs.

While VAC has been far sighted in providing VIP services, such as housekeeping and grounds maintenance, its residential care and housing choices are limited. While VAC will subsidize the cost of a bed in a long-term care home; it will not contribute to the cost of accommodation in a retirement home, supportive housing or an assisted living unit, or to the cost of day programs – even though these options may better meet a veteran's needs. As a result, veterans are often forced – for financial reasons – to move into a long-term care facility rather than a more appropriate setting.

The financial disincentive for veterans to choose assisted living was highlighted in recent research on VAC services for older adults living in rural areas and communities. A veteran in Bobcaygeon, Ontario noted that "There's a deterrent for them to go [to assisted living]. It encourages them to go to the next level of care, which is long term care, where some of those dollars in the nursing home will be paid by the Veterans." ^Footnote52

As the program is currently structured, VAC often pays more than it needs to for residential care while the veteran receives less appropriate services. VAC area counsellors are restricted to specific services covered within each program, and are not able to use resources creatively to meet veterans' needs. It would be more cost-effective and better for veterans' health if they had more residential choices and services (e.g., nursing, personal support, housekeeping) could follow the veteran to the most appropriate setting (e.g., daughter's home, assisted living).

Veterans are asking for more help promoting their health and navigating health and social services.

In 1997, VAC commissioned a review of veterans' care needs. Veterans were asked about the types of services that would enhance their well-being that are not currently available through VAC. They identified the following:

• information on available programs and services
• more emphasis on health promotion and disease prevention
• comprehensive annual geriatric assessments by multidisciplinary teams
• help organizing services and finding providers
• the option to "hire" family members when providers cannot be found for services covered by VIP
• more community-based care (rather than having care provided in one institution)
• more caregiver support and respite care to help spouses caring for veterans and veterans caring for spouses
• more supportive or assisted living options – as a means of delaying or avoiding long-term care homes
• a more consistent approach and tools to assess the need for institutional long-term care.

Veterans are asking for more information to help in promoting their health, navigating health and social services, and getting the programs they need.

The Health Program Review recommended a health promotion and preventive health strategy.

Veterans' request for more emphasis on health promotion was reflected in the Health Program Review Diagnostic and Interim Report (June 2005) ^Footnote53, which recommended that VAC adopt a strategic framework and plan that would:

• focus on healthy living
• integrate health promotion and preventive health into VAC's health programs
• deliver or provide access to health promotion and preventive health initiatives that meet the priority needs of veterans, their families and caregivers
• increase veterans', families' and caregivers' access to health information.

That review identified four priority areas for health promotion that would have the greatest potential health benefit: physical activity, nutrition, mental health and social integration, and self-management of chronic conditions. The Gerontological Advisory Council agrees that these four areas are important but believes that, to promote healthy aging, VAC should adopt a more broadly based health promotion and disease prevention approach, which is integrated with care and support services.

IV. Enhancing Well-being for Canada's War Veterans: Veterans Integrated Services

To meet the needs of Canada's war veterans, the Gerontological Advisory Council proposes a bold new approach to health programs and services, called Veterans Integrated Services (VIS ).

VIS builds on the current strengths in the system as well as the work of the Health Care Program Review. It is designed to promote health, well-being and independence for all veterans in later life. It will also ensure that veterans have care and support when they need it, including end-of-life care.

While this program is designed to meet the needs of Canada's war veterans, the Gerontological Advisory Council believes it will provide a model to meet the needs of all aging veterans and, in fact, of all aging Canadians.

Goal

To help veterans and their families enhance their well-being and quality of life in the later years, age as well as possible, and receive care to support them as their lives end.

Objectives

• To help create environments that promote and support aging well.
• To give all veterans and their families access to information to support aging well.
• To provide assessment services to help veterans and their families identify any factors that threaten their health, well-being or independence.
• To help veterans and their families connect with health and social services that will help them enhance their health and well-being, and maintain their independence.
• To promote an integrated approach to health and social care delivery that caters to the complex needs of aging veterans.
• To fund a range of evidence-based services and interventions to enhance the health and well-being of veterans and their families when those services are not available in the veterans' communities.
• To encourage research to support all aspects of VAC health and social services.

Principles

Collective responsibility. Military service can have both immediate and long-term effects on health and well-being. Canadians have a moral obligation and collective responsibility to support the health, well-being and quality of life of all aging veterans and their families.

Equity. As veterans age, the distinctions used to determine eligibility for programs and services are no longer relevant. Given the long-term impact of military services on health, all older veterans should have the right to access services to help them maintain their health as they age.

Integration and Comprehensiveness. Individual determinants of health do not act in isolation. It is the complex interaction among determinants that affects health and well-being; therefore programs to enhance health use multiple, evidence-based strategies and interventions that target all the determinants of health.

Responsiveness. VAC programs respond in a timely way to meet veterans' needs.

Effective use of resources. VAC programs make effective use of resources by investing upstream to keep people healthy, focusing on community-based services, and shifting resources to provide appropriate services to meet veterans' needs.

Early intervention and outreach. Services provided earlier in life can make veterans more resilient as they age. VAC programs strive to promote and enhance health, to detect signs of stress and vulnerability early, and to intervene in order to maintain or improve quality of life. VAC has a responsibility to seek out veterans and ensure they have the information and supports they need to enhance their well-being.

Needs-based services. Services and supports provided to veterans and their families are based on their health and social needs, rather than their veteran status. If and when veterans have to move from their home to another setting, the services follow the veteran.

Family-based services. Services take into account the needs of the veteran's family and their impact on the veteran's health and well-being. The person who is the primary caregiver in a veteran family does so at great personal cost. A primary caregiver to a veteran continues to receive certain health and social benefits after the veteran's death. Veterans who are caregivers receive support and assistance to fulfill this role.

Engagement and personal choice. Veterans and their families have the opportunity to be actively engaged in identifying their needs and developing health plans. As far as possible, veterans are given choices about the services and supports they use and the setting (e.g., home, assisted living, long-term care) where services are delivered.

Care as close to home as possible. Every effort is made to help veterans age in good health in their home and communities, where they have a sense of belonging.

Veterans Integrated Services (VIS) for Aging Well

Criteria for Participation

1. Military service.

Because all war service veterans are at risk for health and social stresses associated with aging and with military service, they are all eligible to participate in the program.

All veterans who served in the armed forces during World War I, World War II and the Korean War are eligible for the program.

2. Needs.

The type and mix of services that veterans and families receive will depend on an assessment of their health and social needs.

VIS will replace the three existing VAC health programs. It will also eliminate the current complex matrix of eligibility requirements, which are based on veteran status.

Components of the Model

VIS builds on the best of VAC's current services and draws on two integrated health service delivery models that have proven effective with older adults. ^Footnote54, ^Footnote55 It includes the following components.

1. A single entry point for all VAC services that support healthy aging. Veterans will call one number to make the initial contact with the program, and receive a timely referral to appropriate services.

2. Screening and assessment to determine veterans' and families' needs. All veterans and families will be screened and assessed initially to identify any health or social issues, and to determine the type and level of service they need. They will also be reassessed at regular intervals to determine whether their needs have changed. The assessment will include their health promotion needs as well as any care and support needs.

As noted earlier, some veterans will have few needs and may just require information and support to enhance their health; some will have some health and social needs, and will require help managing a chronic illness or maintaining their independence; some will be frail and require more intensive services to help them cope in the community; and some will need long-term care.

3. An interdisciplinary team. VAC will maintain interdisciplinary teams that have the skills and competencies required to promote health and provide services for older adults. In addition to the individuals on VAC teams now – such as client service agents, nurses, social workers, geriatricians, dieticians, occupational therapists, physiotherapists, psychologists -- VAC will adapt or create three key roles:

The early intervention specialist will have expertise in health promotion, disease prevention, the self-help aspects of chronic disease management, and adult education, and be knowledgeable about the health and social service system. He or she will work with individual veterans and families to identify their health promotion needs, develop personalized health promotion plans, and link them with health promotion and disease prevention services in the community that can help them reach their health goals and maximize their independence and well-being. Priority will be given to those health promotion initiatives most likely to enhance well-being and independence: nutrition, physical activity, falls prevention, chronic disease self-management, and physical adaptations in the home. The early intervention specialist will also help the veteran and family navigate the system and find the services and supports they need. He or she will ensure the veteran has a primary care provider who is aware of the health risks associated with aging, assesses the veteran regularly for any early signs of chronic diseases, such as arthritis, and makes appropriate referrals to specialists. The early intervention specialist will also arrange any social services the veteran or family may need to remain independent, such as housekeeping or groundskeeping services.

At the community level, the early intervention specialist will work with veterans organizations and other community services to develop health and social programs that will meet the needs of veterans and families, such as fitness classes for older adults, social programs, walking clubs and chronic disease self-management groups. He or she will also be a resource to the rest of the VAC team and work with other team members to ensure that health promotion is integrated into all VAC health and social programs and services.

The area counsellor will become the care coordinator and have expertise in assessment and case management. He or she will be responsible for coordinating services for veterans who require some health and social services to maintain their independence, including nursing services, drugs, assistive devices and other medical services. The care coordinator, supported by the community support assistant will manage a fairly large caseload of veterans who have health needs but whose health is relatively stable. He or she will have more flexibility than area counsellors have now to choose how to use resources to help clients, and will be able to offer options such as day programs and assisted living units. The care coordinator may refer some veterans to the early intervention specialist for advice on how to enhance their health. He or she will also refer a veteran whose health begins to deteriorate to the high needs care manager.

The high needs care manager will have expertise in aging, disabilities associated with disease processes and end-of-life care, and will be responsible for managing the care of veterans or family members who are frail or disabled and have more intense care needs. He or she will have a caseload of 30 to 40 people, and will work closely with the veteran's primary care provider, home care service manager, respite care services and organizations responsible for providing long-term care services to ensure the veteran is receiving timely, appropriate care. The high needs care manager will be available to provide a rapid response to any emergency, and will be able to mobilize resources quickly to meet a veteran's changing health needs. The goal will be to maintain the veteran in the community as long as appropriate, to ensure the veteran who requires emergency department interventions or hospital stays is able to return home with appropriate services, to negotiate institutional services for veterans who have to move from home to a rehabilitation centre, assisted living facility or a nursing home, and to ensure that veteran receives evidence-based care in all settings.

4. Innovative models of service delivery, including intensive home support and a greater range of residential choices for veterans. VAC will use its knowledge of an aging population and its resources to develop and evaluate innovative models of service that have the potential to enhance veterans' well-being and help them age well, including: intensive home supports, assisted living arrangements, supportive housing and the development of small specialized long-term care homes designed to meet the needs of veterans with dementia.

Different residential models may allow veterans to live more independently in their communities and defer the need for more costly nursing home care. It may also avoid the negative impact of separating veteran families. For example, an apartment in an assisted living facility may allow veterans and their spouses to stay together when they can no longer manage both care giving and homemaking tasks at home – instead of moving one partner into a long-term care facility and forcing them to live apart, which could have a negative impact on both partners' health. In other situations, a veteran may need the security provided by assisted living but not need the personal care of a nursing home.

5. Ability to move resources. The early intervention specialist, care coordinator and high needs care manager will have the authority and flexibility to shift and allocate resources to meet veterans' health and social needs.

6. Outreach to war veterans. VAC will work with veterans' organizations (e.g., advertising, word of mouth) to inform all war service veterans of the Veterans Integrated Services and encourage them to participate.

7. A comprehensive database. VAC will develop a database that will allow the department to collect and analyze data on the health and social needs of veterans and their families, the range of services they use, and their impact on health, well-being and independence. The data will be used to evaluate the effectiveness of different services, and the impact of an integrated service delivery model on veterans' well-being. The data can also be used to improve services.

8. Research. VAC has a unique opportunity to contribute to our understanding of aging and the mix of services and supports that can help people age well. Through VIS, VAC will be providing and testing innovative services. The program will encourage and support research that will lead to better care for older adults.

The best practices identified through the Veterans Integrated Services should be shared with the provinces and territories. The lessons learned should be used to advocate for broader health and social policies that enhance health and well-being in the later years, and to improve access to effective integrated services for all aging veterans and for all older adults.

The Model in Action

A war veteran, who has never accessed VAC services, sees an ad in SALUTE promoting VIS. He or she or a family member calls the VAC National Client Contact Centre to ask about the program. The receptionist would provide a scripted brief overview of VIS and then administer a screening tool (see sample, Appendix 1, PRISMA-7) to determine whether the veteran should be referred to the Early Intervention Specialist, the Care Coordinator or the High Needs Care Manager (see Figure 8).

Figure 8 – Access to Veterans Integrated Services (Text Version)

Figure 8 shows the various steps that are taken when a Veteran or a family member first calls VAC's toll-free number (NCCN) to inquire about programs and services. The NCCN represents the single point of entry to services in which potential clients are screened and if required, referred to appropriate specialists in the Department. Referrals can also be made from one specialist to another.

It is unlikely that the first contact high needs veterans will be via a phone call to the NCCC. These veterans are much more likely to already be VAC clients and receiving care coordination. A change in their health needs would trigger a referral to the High Needs Care Manager who would arrange for more intense services to sustain them in their own homes, make arrangements for long-term care, or for end-of-life care. The exception could be a veteran who has been well or has not used any VAC services, and who suddenly experiences a serious health event such as a stroke or an accident that changes his or her health status.

The following scenarios¹ describe how different veterans would benefit from VIS and how the model would work.

¹Because 91% of veterans are male, the scenarios use “he” to describe the veteran; however, the Gerontological Advisory Council recognizes that 9% of war service veterans are women and the scenarios apply to female veterans.

Scenario One: Referral to an Early Intervention Specialist

Screening results indicate the veteran is in relatively good health but could benefit from health sustaining or enhancing interventions or needs help navigating services available in the community.

The veteran is referred to the Early Intervention Specialist who does an assessment and determines that he does not have access to primary care, is overweight and does not engage in any exercise -- despite having no mobility limitations. The veteran and his spouse live in a small house, but are socially isolated. They find groundskeeping and snow clearance onerous.

The Early Intervention Specialist:

• determines whether they can access a community service at reduced rates for seniors and whether they should access VAC's groundskeeping service
• helps the veteran locate a primary care provider and encourages him to have a comprehensive health assessment
• introduces the veteran to a seniors' walking program that includes a number of social activities as well as age appropriate physical activities or to a local seniors' club that provides a range of activities that interest him and his spouse.

Should the veteran have a chronic illnesses such as arthritis, diabetes, depression or hypertension, the Early Intervention Specialist would insure the veteran understands how to manage these illnesses so they are under control as much as possible. This would include ensuring the veteran understands the drug regimen, diet and other self management activities.

A critical component of the Early Intervention Specialist role is to stay in touch with the veteran to monitor his health status, encourage the veteran and spouse to participate in the activity or social plan, and to continue to help them navigate the system so they receive services they require.

Scenario Two: Referral to a Care Coordinator

Screening results indicate that the veteran has a number of health needs.

The veteran is referred to a Care Coordinator who makes a home visit and assesses the veteran and his spouse and, with the veteran's permission, contacts the family physician to discuss their health status including ongoing illness management plans. This contact reveals that the veteran has arthritis and his wife has dementia. The veteran's wife has little short-term memory but can recognize family members, and is very resistant to bathing and other personal hygiene activities. The Care Coordinater completes a family assessment and determines that the veteran is functioning as a caregiver, is tired and scared about the future, and needs respite and ongoing support. The assessment also reveals the need for home maintenance services and for safety bars in the bathroom.

The Care Coordinator:

• contacts the provincial home care program to arrange for assistance with personal care for the veteran's wife and a day program that will give the veteran some respite and his wife social stimulation
• maintains contact with the veteran to ensure that the home care referrals produce the needed services
• arranges for home maintenance services, and has the program pay for them directly – rather than requiring the veteran to arrange for the service and submit receipts
• arranges for home renovations
• encourages the veteran to see his family physician to determine whether a referral to a specialist would help manage his arthritis
• refers the veteran to the Early Intervention Specialist to discuss ways to promote and maintain his health
• coordinates the VAC services and the provincial services to ensure there are no gaps
• works with the veteran and the home care program to plan for future residential care for the veteran's wife, exploring the possibility of nursing home care
• maintains close communication with the veteran and his wife to be a support to the veteran and to monitor the home situation.

Scenario Three: Referral to the High Needs Care Manager

Screening results indicate that the veteran has complex needs.

The High Needs Care Manager is contacted. (The veteran could also be referred to the Care Coordinator who would identify the complex, extensive needs and contact the High Needs Care Manager.) The High Care Needs Manager visits the veteran in a hospital and undertakes an assessment. The veteran has had a stroke, is paralyzed on his right side, and cannot walk. He requires assistance with eating and cannot do his own personal care, but both he and his spouse want him to return home rather than go to a nursing home. To be able to manage at home, the house will need renovations to allow access and the veteran will need a range of rehabilitation services, nursing and personal care services, as well as the services of a health care aide to transfer him in and out bed each morning and evening, and access to handicap transportation services to attend doctor's appointments and for social outings. His 84 year old spouse will need assistance with homemaking as well as groundskeeping services.

The High Needs Care Manager in consultation with the family and health care team determines that the veteran's desire to return home should be honoured, that the costs are not higher than nursing home care, and that his rehabilitation outcome is likely to be better at home.

Before the veteran returns home, an integrated services plan is designed by the High Needs Care Manager, the veteran and his family. The High Needs Care Manager implements the integrated services plan and:

• arranges home renovations
• contacts the home care program to arrange for nursing, homemaking, physiotherapy and occupational therapy to support his rehabilitation
• purchases additional homemaking services to supplement that provided by home care
• arranges for groundskeeping services
• monitors the veteran and spouse closely to ensure the home arrangements are sustainable
• maintains close communication with the veteran's physician to understand and support the medical plan
• monitors medication.

Six months after his return home, the veteran has a fall and ends up in the emergency department. The High Needs Care Manager is contacted and conducts another assessment to determine whether the veteran is able to continue to manage at home. The veteran and his wife decide that managing at home is becoming too difficult and it is time to move out of their home. The HNCM considers the possibility of using assisted living, taking into consideration the level of needs and the veteran's and his wife's preferences. Assisted living does not appear appropriate in this case, so the HNCM explains the options of a priority bed versus a community bed and helps them make an informed choice. She works with the home care program to secure the community facility they prefer, and continues to arrange for some extra nursing care for the veteran while in the home.

V. The Future is Now

The proposed Veterans Integrated Services is more comprehensive, flexible and responsive than VAC's current health programs. It will combine three distinct programs into one and expand the services available, making it easier for VAC staff to move resources and use them effectively to meet veterans' needs. VIS will be available to all war veterans based on need, and it will provide access to a wider range of health and social services – including more residential choices. By providing information and support for health promotion, VIS will help veterans enhance their health and well-being. By providing more integrated, coordinated services, VIS will ensure that veterans do not slip through the cracks in provincial health systems. Through VIS, VAC will be able to keep the promise to our veterans. The Gerontological Advisory Council believes that VIS will not only lead to better quality service for veterans, but it will prove to be cost effective.

VAC has an opportunity once again to reset the bar for health and social services in Canada. It is possible to establish an integrated system of health and social services for war veterans that can enhance well-being, help people age well, allow our aging veterans to spend their later years where they want to be – with family and friends, and avoid or delay the need for institutional care.

The Gerontological Advisory Council believes VIS has the potential to be a model of care for all older adults, and to set the principles for future services for Canadian Forces Veterans as they age.

As the Gerontological Advisory Council noted at the beginning of this paper, there is no time for extensive debate. Most of Canada's war veterans are in their 80s, and about 2,000 are dying each month. If we are to make a difference in the quality of their and their family's lives, we must act quickly, and we must act now. It is time to keep the promise.

Appendix 1

PRISMA-7 Screening Tool

PRISMA-7 Screening Tool

Client Question	Yes	No
Are you older than 85 years?
Are you male?
In general, do you have any health problems that require you to limit your activities?
Do you need someone to help you regularly?
In general, do you have any health problems that require you to stay at home?
If you need help, can you count on someone close to you?
Do you regularly use a cane, a walker, or a wheelchair to move about?
Total Checked